Clinical Reasoning in the Assessment and Planning for Intervention for Autism Spectrum Disorder

Core Difficulties

Individuals with ASD experience pervasive primary social challenges resulting from impairment in understanding and responding to social information (Dawson, Meltzoff, Osterling, Rinaldi, & Brown, 1998; Travis & Sigman, 1998). As children, those with ASD rarely show typical development of imitation, sharing of attention and focus with social partners, orienting to socially important stimuli, and the perception and expression of emotions, all of which interfere with the development of social reciprocity (Dawson et al., 1998; Osterling & Dawson, 1994). Communication symptoms involve atypical language development, including delayed acquisition of single words and/or phrase speech, delayed or atypical expansion of abilities, loss of previously developed skills, and difficulties with conversation and socially appropriate language use (Stephanos & Baron, 2011). Past research has indicated that as many as 50% of individuals with ASD remain nonverbal (Rutter, 1978); however, more recent research has suggested that up to 40% of children develop some speech by 9 years of age, with only 15% remaining nonverbal (Lord et al., 2006). Spoken language impairments often include echolalia, pronoun reversal, and difficulties with pragmatic language use (Tager-Flusberg, 1999, 2000). Communicative behaviours involved in play with others, such as imitation and role-playing, are often an additional area of deficit (Haq & Le Couter, 2004).

RRBs manifest as lower and/or higher level behaviours. Lower level behaviours include repetitive motor movements such as hand flapping, rocking, and spinning, whereas higher level behaviours include circumscribed interests, fixations on established behavioural routines, preoccupations, interests with certain topics (e.g., street signs or birth dates), or attachment to unusual objects such as toilet brushes or spoons (APA, 2013). Some individuals with ASD may also manifest adverse reactions (i.e., over- or under-stimulation) to sensory input, which can exacerbate the socio-communicative and behavioural impairments (Glod, Riby, Honey, & Rodgers, 2015).

It is very important to understand the heterogeneity in phenotypic expression beyond the classical ASD presentation (Szatmari et al., 2002). The severity and number of symptoms vary across individuals, and in some cases and domains, across time (Richler, Huerta, Bishop, & Lord, 2010; Szatmari et al., 2002). As such, ASD is considered a “spectrum” disorder with affected individuals demonstrating differential core and secondary impairments (National Research Council, 2001). Estimates of comorbid conditions in individuals with ASD vary significantly from 4% to 81% (e.g., Davis et al., 2011; Leyfer et al., 2006). The most common comorbid condition is intellectual disability (ID), with an estimated comorbidity rate between 40% (Baird et al., 2000) and 69% (Chakrabarti & Fombonne, 2001). Mood disorders are also very common in the ASD population, with specific phobia (44%), obsessive compulsive disorder (37%), attention-deficit/hyperactivity disorder (ADHD; 31%), depression (13%), separation anxiety disorder (12%), oppositional-defiant disorder (7%), and generalized anxiety disorder (2%) reported as common secondary diagnoses in a sample of 109 mid- to high-functioning children and adolescents ranging from 5 to 17 years of age with ASD (Leyfer et al., 2006). It should be noted that the rate of major depression increased to nearly 24% when subsyndromal cases were included (i.e., children who fell just short of meeting criteria for this disorder).

Overall, outcomes for individuals with ASD vary greatly, and many individuals will exhibit significant impairment over their lifetime (Howlin, Goode, Hutton, & Rutter, 2004). As such, effective assessment and intervention approaches that can identify a child’s unique behavioural and related challenges at an early age will afford opportunities for earlier access to interventions that may help adjust the child’s developmental trajectory to yield a more positive outcome in adolescence and adulthood.

Background Information

Jonas’ attainment of developmental milestones was delayed. He did not walk unaided until 21 months of age, speak his first words until 36 months of age, or speak in sentences until 7 years of age. He experienced daily nocturnal enuresis at the time of assessment. A prior assessment by a pediatrician at 7 years of age resulted in a diagnosis of Global Developmental Delay, although no formal assessment (e.g., psychological, speech, sensory) was conducted. He underwent genetic testing for a suspected syndrome; results indicated no match with any known genetic conditions at the time.

Jonas’ older brother was diagnosed with ADHD though no other family member has a documented learning or behavioural challenge. It is often the case that parents or siblings of a child with ASD display features of the disorder (e.g., language, social, and/or behavioural challenges), although this is not always true (Sucksmith, Roth, & Hoekstra, 2011). Jonas was described as a goofy, likable, odd, and active boy who desires to engage in many activities and who is becoming more aware of his personal challenges. He is overly and easily frustrated when unsuccessful in activities that he undertakes. He is highly distractible, especially in active environments. He works best in structured, routinized contexts and often requires notification and preparation for changes in routine. His energy level varies from lively to lethargic and he enjoys down time after periods of activity. He has several close friends; however, they are all neighbourhood children who are younger than Jonas and he has no same-age friends at school. Indeed, he struggles to engage socially with other children and prefers to interact only with familiar individuals. He presents with frequent hand mannerisms in the form of waving his fingers in the air while his arms and hands are extended, and putting his fingers to his mouth while he tenses his arms and hands.

Regarding academics, Jonas enjoys school and is well-liked by his teachers. He is currently integrated into a typical classroom with a modified program and accommodations to support his learning. He receives pull-out support during French class. He is reported to enjoy social studies, art, and band. He dislikes math and language arts. A review of his current Individual Program Plan (IPP) indicates supports pertaining to a focus on concrete aspects of the curriculum, a reduction in the number of Specific Learner Outcomes, and the use of task analysis to break larger tasks into smaller units. Specific goals on his IPP include development of his expressive and receptive language skills, development of organizational skills, and enhancement of core academic (reading, writing, and math) skills.

Several important features are noteworthy at this point in the assessment process, even though Jonas has not yet been seen for assessment. Having an appreciation of Jonas’ delayed attainment of developmental milestones affords an understanding of the possible influence that such a delay may have upon subsequent development. As his early language and motor skills were slow to develop, subsequent development of these domains may continue to fall further behind his peers. Importantly, no evidence of intervention for these concerns was provided, despite his diagnosis at age 7. Indeed, an early delay in language and motor skills may result in more substantial concerns later in childhood. In addition, the presence of ADHD in the sibling is indicative of a potential propensity toward attentional challenges that may be relevant for Jonas. Most informative, however, is the description of Jonas’ current behavioural issues and challenges. His characterization as an odd child who struggles substantially with social interactions, particularly with peers, is an important feature to attend to. In addition, his challenges with emotional and behavioural regulation are often seen in children with ASD, as well as other clinical conditions (e.g., ADHD, specific learning disability, and/or ID). His repetitive motor mannerisms are another common feature of ASD, though not a universal characteristic by any means. Regarding the school setting, Jonas is reported to enjoy school and some subjects; however, his behavioural challenges are persistent despite the support that he is receiving. Importantly, the school provides support to Jonas in the absence of specific assessment data on his current cognitive, academic, and behavioural functioning. Although this situation is not desirable, it is also not uncommon as many school systems struggle to obtain detailed assessment information for all their students due to capacity of their school-based professionals.

Assessment Protocol

Given the presenting issues and concerns, a comprehensive assessment plan was developed to examine Jonas’ cognitive, academic, behavioural, and attentional functioning in addition to a specific assessment for symptoms of ASD. This assessment plan included the following:

Initial Assessment Results

Results of the cognitive assessment indicated extremely low cognitive abilities across all five domains (Verbal Comprehension Index = 69, Visual Spatial Index = 56, Fluid Reasoning Index = 61, Working Memory Index = 69, Processing Speed Index = 60, Full Scale Inteligence Quotient = 57) evaluated by the WISC-V. In alignment with this, Jonas’ adaptive functioning as evaluated by the ABAS-3 fell into the extremely low range across all domains evaluated by both the parent (conceptual = 61, social = 62, practical = 48) and teacher (conceptual = 65, social = 64, practical = 56) forms. Jonas’ performance on the WIAT-III was commensurate with his demonstrated cognitive ability; all domains fell into the extremely low range (total reading = 69, written expression = 62, mathematics = 66, math fluency = 52, oral language = 68). The behavioural rating scales (BASC-3) indicated clinically significant concerns with atypicality (odd behaviour), withdrawal, attention problems, and functional communication. In addition, adaptability, social skills, and leadership were rated as at-risk.

The results of the cognitive and adaptive measures are in alignment with the pediatrician’s initial impressions and provide support for Jonas’ developmental challenges. Importantly, there is some heterogeneity in the degree of challenges across the five indexes of cognitive functioning and so consideration to his unique cognitive profile should be given. In addition, the type and severity of his adaptive difficulties are considered when determining whether he meets criteria for ID and, if so, what the severity specifier should be. It is important to note that even though Jonas’ school had already recognized him as a student with a mild ID, confirmation of Jonas’ challenges with cognition and adaptive skills is of primary importance as no formal evaluation for this concern had been conducted previously. Indeed, such lack of robust assessment is not uncommon and should be of concern for ethical school psychologists. The BASC-3 suggested several areas of concern; these are generally in alignment with common behaviours demonstrated by children with ASD who often present with odd or atypical behaviour, desire for aloneness, difficulties with focus and attention, and communication problems (though these are by no means universal challenges for this population). The additional “At-Risk” concerns are also not uncommon in children with ASD as they frequently struggle with unanticipated change and social interactions.

At this point, it is important to note that none of the above assessment results is strongly indicative of ASD. Indeed, many children with other developmental challenges, including ID, ADHD, or mood disorders will present with similar assessment results, depending upon the unique challenges experienced by the child. As such, a formal assessment process to examine ASD-related symptoms is pivotal to determine whether Jonas does indeed present with unique ASD behaviours sufficient to meet the diagnostic criteria for the disorder.

ASD Assessment Results

Jonas completed the ADOS-2, Module 3, which is a standardized assessment of communication, social interaction, and imaginative use of play materials. Module 3 is designed for verbally fluent children and consists of a series of structured and unstructured situations that allow for the observation of ASD-related symptoms. Jonas’ observed behaviour during the assessment indicated some mild symptoms related to ASD. Specifically, he struggled with conversation, his use of gestures was limited, and his social overtures were often awkward. In addition, he presented with a prominent hand and finger mannerism. Jonas’ parents also completed the ADI-R, a semi-structured comprehensive interview designed to aid in the diagnosis of ASD. They reported that Jonas’ eye contact was poor and he did not initiate or respond to social smiling as a young child. In addition, his range of facial expressions was very limited and his expressions were often inappropriate to the situation. He did not engage in pretend play with peers and did not approach or respond to other children’s social approaches. He did not show or direct his parent’s attention toward objects of interest, nor did he share objects with others. He did not seek to share enjoyment with others. He rarely offered comfort to others in distress. In general, the quality of Jonas’ social overtures was very poor, as were his responses to others’ social overtures. He did not point at objects nor did he engage in any communicative, conventional, or instrumental gestures. He did not imitate others’ actions nor did he engage in imitative or imaginative play. He did not engage in social chat or conversation with others, and he presented with frequent inappropriate statements that were highly embarrassing to others. He has and continues to present with strong and perseverative interests (e.g., wrestling and, to a greater extent, trucks and trailers). He has prominent hand and finger mannerisms as well as a full body mannerism in the form of repetitive jumping. He lined his cars and other objects up as a child and would become distressed if the order was interfered with. He also presented with a strong olfactory sensory seeking behaviour and was driven to smell any object that he touched.

Diagnostic Conclusion

Given the results of the assessment process, several diagnoses should be given consideration. His cognitive and adaptive challenges are indicative of a mild intellectual disorder (MID) diagnosis as his delayed adaptive functioning suggests challenges with conceptual (academics), social (perception of and response to social cues and emotional regulation), and practical (self-care and hygiene) domains of functioning. Such delays appear to be more accurately described within the mild classification (as opposed to moderate). In determining whether Jonas also meets criteria for an ASD diagnosis, consideration of the social affect and behavioural challenges that children with MID may demonstrate is of primary importance. Notably, the majority of atypical behaviours observed during the administration of the ADOS-2 and endorsed by Jonas’ parents during the ADI-R are not ones that children with a non-ASD developmental disorder (e.g., MID) demonstrate. Indeed, the prowess of the ADOS-2 and ADI-R lies in their ability to identify and appreciate behaviours that, typically, only children with ASD display. As such, given the type, variety, and quality of behaviours ascertained via the ADOS-2 and ADI-R, Jonas also meets criteria for ASD, with accompanying intellectual and language impairment. The specifiers “with accompanying intellectual and language impairment” are used here as outlined in the DSM-V (APA, 2013, p. 51) to account for Jonas’ cognitive and language delays, as these are best understood in the context of his ASD diagnosis rather than as concurrent conditions or diagnoses. Given the results of the current assessment, he is classified as Level 2 for severity in both the social communication and RRB domains, indicating the need for substantial support in these areas.

Strategies to Address Maladaptive Behaviour

A key component of any intervention for individuals with ASD is the development of strategies to reduce or mitigate maladaptive behaviour (Leader & Mannion, 2016). In Jonas’ case, several of his ASD symptoms may be viewed as maladaptive or disruptive (e.g., hand mannerisms, poor frustration tolerance, ritualistic behaviour). Working with Jonas’ parents and teachers from a functional behavioural analysis and/or positive behaviour support perspective may help them identify possible underlying functions of Jonas’ behaviour. These approaches are geared at helping the adults in Jonas’ life teach him functionally equivalent alternative responses that, while serving a similar purpose, will be less disruptive and more socially appropriate. For example, teaching Jonas to request a break when he is becoming frustrated, and to initiate calming activities during the break, may serve the same regulating function as a behavioural outburst in a more appropriate manner.

Tools to Enhance Self-Regulation Skills, Emotional Awareness, and Emotional Control

Teaching Jonas, his family, and his school team tools to build his self- and emotional-regulation skills will be important. For example, The Zones of Regulation (Kuypers, 2011) is an evidence-based tool that promotes self-regulation and emotional control using a developmentally sensitive, stepwise approach. Jonas’ teacher could implement such programming in collaboration with his resource teacher or learning specialist in the context of classroom-wide activities and instruction. Parents could also incorporate Zones concepts into home routines, family activities, and general conversations as both teaching interactions and modelling opportunities. Emotion-based vocabulary and self-regulation tools can be adapted and implemented across environments to support Jonas’ awareness of his own sensory and emotional experiences and needs.

Strategies to Assist With Initiating and Maintaining Friendships

Although Jonas has some younger neighbourhood friends and is socially motivated, he has not been able to make or keep same-age friends at school and he struggles to engage socially with others. As such, formal programming to support Jonas’ development of ecologically valid social skills is recommended. For example, the Program for the Education and Enrichment of Relational Skills (PEERS^®; Laugeson & Frankel, 2010) is a manualized, social skills training intervention for youth with social challenges. PEERS^® has a strong evidence base for use with adolescents with ASD. It can be administered in a community-based group format or within a school-based curriculum (Laugeson, 2013a). In the absence of formal PEERS^® training, the parent book, The Science of Making Friends (Laugeson, 2013b), along with its companion DVD, is widely available to guide families and school teams in helping socially challenged teens to build needed social skills.

General Accommodations to Optimize Learning and Independence

Given Jonas’ ASD diagnosis, intellectual impairments, adaptive delays, and language delays, he will require ongoing academic accommodations, modified programming, and life skills training. Supports at home and school should focus on incorporating functional skills (e.g., self-help skills, community use skills, safety concepts) as well as equipping parents and teachers to provide ASD-sensitive instruction and support.

Transition Support, Long-Term Planning, and Parent Counselling

As a key referral question centered on planning for Jonas’ upcoming school transition, it will be important that recommendations include assisting the receiving school to arrange appropriate supports for Jonas. A collaborative meeting between the family, the current school team, and the receiving school team may be helpful and productive. Sharing resources, strategies, and ensuring that all parties can plan proactively will lead to a smoother school transition for Jonas and his family. Regarding longer term planning, parents should be counselled to prepare for the pervasive nature of ASD and the likelihood that Jonas may require financial and legal arrangements, such as guardianship, vocational supports, and assured income in the future. Finally, parent counselling and support groups may also be a helpful component of Jonas’ short- and long-term intervention plan as many parents of children with ASD experience a range of emotions and reactions to an ASD diagnosis (Abbott et al., 2013).